Implant placement systems and one-handed methods for tissue fixation using same

ABSTRACT

Described herein is a simplified placement system and method for a tissue graft anchor by which a surgeon may introduce one or more sutures into a hole in a boney tissue, apply a precise amount of tension to the sutures to advance a soft tissue graft to a desired location, and then advance the anchor into the bone, preferably while maintaining the requisite pre-determined suture tension and without introducing spin to the suture. Particularly preferred embodiments allow for the one-handed operation. To that end, embodiments in which relative axial movement between the inner tensioning device and outer driver device is optionally physically constrained, for example by means of cooperating and/or compressive elements disposed in the respective hub and handle portions, are described herein.

PRIORITY

This application is a continuation-in-part of U.S. patent applicationSer. No. 15/012,060 filed Feb. 1, 2016 (now U.S. Pat. No. 9,566,066issued Feb. 14, 2017), which, in turn, is a continuation-in-part of U.S.patent application Ser. No. 14/972,662 filed Dec. 17, 2015, which, inturn, is a continuation of U.S. patent application Ser. No. 14/636,389filed Mar. 3, 2015 (now U.S. Pat. No. 9,226,817 issued Jan. 5, 2016),which, in turn, claims the benefit of U.S. Provisional Application Ser.Nos. 61/966,744 filed Mar. 3, 2014; 61/998,391 filed Jun. 26, 2014;61/998,766 filed Jul. 7, 2014; and 61/999,405 filed Jul. 26, 2014, thecontents of each of which are hereby incorporated by reference in theirentirety. This application also claims the benefit of U.S. ProvisionalApplication Ser. Nos. 62/284,151 filed Sep. 21, 2015 and 62/392,789filed Jun. 11, 2016. The contents of the afore-noted priorityapplications are hereby incorporated by reference in their entirety.

TECHNICAL FIELD OF THE INVENTION

The present invention relates generally to the field of endoscopic andarthroscopic surgery and suture anchor systems and devices for usetherein. More particularly, the invention relates to a knotless sutureanchor device utilized to secure soft tissue to bone or a boney surfaceto preclude the need to tie surgical knots to secure the tissue in placewith the device. Specifically, the invention relates to a simplifiedanchor system and method by which the surgeon may introduce one or moresutures into a hole in the bone, apply tension to the sutures to advancethe soft tissue to a desired location, and then advance the anchor intothe bone while maintaining the suture tension and graft position.

BACKGROUND OF THE INVENTION

The use of implants to affix tissue grafts to bone is well known in theorthopedic arts. Common procedures in which such implants are usedinclude, for example, the repair of rotator cuff tears, the repair oftorn ligaments in the knee, among others. In these procedures, a socketis drilled or punched in the bone at the attachment site and a graft issecured to the bone using an implant placed in the socket. The graft maybe secured to the implant by sutures, or, alternatively, an end of thegraft may be placed in the socket and secured directly by an implant.

In rotator cuff repair, implants commonly referred to as “anchors” areused. These anchors occur in two types: conventional anchors in whichthe suture is passed through the cuff after anchor placement, and“knotless” anchors in which the suture is passed through the cuff priorto anchor placement. In the former case, the graft is secured in placeby tying knots in the suture after it has been passed through the cuffso as to secure the cuff in the desired location. Conversely, as thename implies, when using a knotless anchor, the sutures are passedthrough the cuff and through a feature of the anchor such that when theanchor is inserted into the socket, the suture position is secured bythe anchor. Accordingly, the tying of knots is not required. This isparticularly advantageous when performing endoscopic (arthroscopic)repairs since the tying of knots arthroscopically through a smalldiameter cannula can be difficult for some surgeons and, moreover, thereis an opportunity for tangling of the sutures.

Many anchors, both conventional and knotless, are supplied to thesurgeon mounted on a driver—a device that the surgeon uses to place theanchor in the prepared socket in the bone. In the case of threadedanchors, the driver has a form like that of a screwdriver, and indeedfunctions in the same manner. The proximal portion of the device forms ahandle that is grasped by the surgeon. Distal to the handle, an elongatedistal portion has formed at its distal end features for transmittingtorque to an implant. Some anchors, generally metallic anchors such as,for instance, the Revo® Suture Anchor by Conmed Corporation (Utica,N.Y.) and Ti-Screw Suture Anchor by Biomet Corporation (Warsaw, Ind.),have a protruding (male) proximal portion with a cross-section suitablefor transmitting torque (typically hexagonal or square) and a transverseeyelet formed therein. The driver for such devices has a complimentarysocket (female) formed in its distal end and a cannulation that extendsfrom the interior of the socket to the proximal handle portion of thedevice. Sutures loaded into the eyelet of the anchor extend through thedriver cannulation (or “lumen”) and are removably secured to the handleso as to retain the anchor in the socket of the driver. Such anchors arereferred to in the orthopedic arts as “pre-loaded”, meaning that suturescome loaded into an anchor that is ready for placement by the surgeonusing the associated driver.

Other threaded anchors have a socket (female) formed in their proximalends. Once again, the socket has a cross-section suitable fortransmitting torque that is typically polygonal, usually square orhexagonal. Typical of these are the V-LoX™ family of titanium sutureanchors by Parcus Medical (Sarasota, Fla.) and the ALLthread™ anchors byBiomet Corporation (Warsaw, Ind.). The drivers for such devices have aprotruding (male) torque-transmitting feature complementary to thesocket (female) formed in the proximal end of the anchor. These driversmay be cannulated to accommodate sutures that are preloaded into theanchor in the manner previously described, with the sutures being eitherfor the purpose of securing tissue after anchor placement, or for thepurpose of removably securing the anchor to the driver, wherein thesutures are released from the driver after the anchor is placed in thebone and subsequently removed and discarded so as to allow removal ofthe driver from the anchor. The depth of the socket in the proximal endof the implant must be sufficient to enable transmission of therequisite torque needed for anchor placement without deforming orfracturing the implant. As the maximum depth of the torque-transmittingportion is generally limited only by the configuration of the anchor, itis considered to be matter of design choice. Indeed, the implant mayhave a cannulation that extends axially through the implant as well as atorque-transmitting cross-section forming a substantial proximal portionor the entirety of the implant's length. Implants of the Bio-TenodesisScrew™ System by Arthrex, Inc have a cannulation with a constanttorque-transmitting cross-section, and are used with a driver having atorque-transmitting portion that extends beyond the distal end of theanchor, wherein the portion of the driver extending beyond the anchorand a suture loop in the driver cannulation are used together to insertthe end of a graft into a prepared socket prior to placement of theimplant.

Knotless suture anchor fixation is a common way of repairing soft tissuethat has been torn from bone. Illustrative examples of such “knotless”anchors include the Allthread™ Knotless Anchors by Biomet Incorporated(Warsaw, Ind.), the SwiveLock® Knotless Anchor system by Arthrex,Incorporated (Naples, Fla.), the HEALIX Knotless™ Anchors byDepuy/Mitek, Incorporated (Raynham, Mass.) and the Knotless Push-InAnchors such as the Knotless PEEK CF Anchor by Parcus Medical (Sarasota,Fla.). The procedure requires drilling or punching of holes into aproperly prepared boney surface. After suture has been passed throughsoft tissue, the suture anchor is introduced into the socket and driveninto the socket using a mallet or by screwing the anchor into the socketusing a driver device. These driver devices typically resemble ascrewdriver in form, having a proximal handle portion for applyingtorque or percussive force, and an elongate rigid distal portion havingat its distal end a torque or percussive force-transmittingconfiguration. In the case of torque-transmitting drivers used withthreaded anchors, the distal end of the driver typically has an elongatehexagonal or square distally extending portion that, through couplingwith a lumen in the anchor having a complementary cross-section,transmits torque to the anchor. The lumen may extend through anchor sothat the distal portion of the driver protrudes from the distal end ofthe anchor and rotates with the anchor during anchor placement.

Because the suture is drawn into the prepared socket along with theanchor during anchor placement, it is essential that a suitable lengthof suture extends between the graft and the anchor so that when theanchor is suitably positioned within the socket, the graft is properlypositioned. Determining the proper length of suture to allow between theanchor and the graft so as to achieve optimal graft positioning iscomplicated since suture(s) may twist (a process referred to in theorthopedic arts as “suture spin”) during anchor placement, therebyshortening the effective length and changing the final graft positionand/or undesirably increasing the suture tension.

U.S. Pat. No. 6,544,281 to ElAttrache et al. describes a cannulatedanchor placement system having a rotating inner member (which acts asthe driver) and a stationary outer member, wherein the rotating innermember serves to drive the threaded anchor. The rotating “driver”extends past the distal end of the anchor and is inserted into aprepared socket in the boney surface. A suture loop formed distal to thedistal end of the driver “captures” or “secures” sutures attached to agraft or the graft itself to the distal end of the driver. The distalend of the driver is then inserted into the socket to a proper depth foranchor placement thereby drawing the graft to the desired position priorto placement of the anchor. The anchor is then threaded into the socketto the predetermined depth. This system constitutes an improvement overother commercially available alternatives. However, because the graft orsutures are secured to or pass through the distal end of the rotatinginner (or “driver”), torque is transmitted not only to the anchor butalso to the graft or sutures attached thereto by the suture loop.Accordingly, twisting of the sutures or graft frequently occurs, therebychanging the resulting suture tension and/or the graft position (aprocess referred to in the orthopedic arts as “graft shift”).

U.S. Pat. No. 8,663,279 by Burkhart et al. describes a knotless anchorsystem similar in construction to that of ElAttrache et al. A “swivel”implant having formed therein an eyelet is releasably and pivotablymounted to the distal end of a driver distal portion that extendsdistally beyond the distal end of an anchor. After sutures are passedthrough the graft, they are threaded into the eyelet of the swivelimplant at the distal end of the driver. The distal end of the driverwith the swivel implant is then inserted into the socket. By pulling onthe suture tails, the graft is moved into position and secured byscrewing the anchor into the socket. However, because the sutures/graftare secured to the driver by means of the swivel eyelet implant, thetorque that may be transmitted to the sutures/graft is limited. However,torque transmission is not eliminated since the swivel implant isretained in the driver distal end by a suture loop under tension, whichextends through the cannula of the driver to the driver's proximal endwhere the suture ends are cleated. While an improvement over theElAttrache anchor system, suture spin is not eliminated in all cases,and indeed, cannot be since the suture-retaining implant is mounted tothe driver, which rotates during anchor placement. As such, some levelof torque transmission due to friction between the driver distal end andthe swivel eyelet implant is inevitable.

Other knotless anchors such as the ReelX STT™ Knotless Anchor System byStryker® Corporation (Kalamazoo, Mich.) and PopLok® Knotless Anchors byConMed Corporation (Utica, N.Y.) have complex constructions and requirethat the surgeon perform a sequence of steps to achieve a successfulanchor placement with the desired suture tension and proper cuffposition. The sequence of steps adds to procedure time and createsopportunities for failure of the placement procedure if a step is notperformed properly.

Accordingly, there is a need in the orthopedic arts for a knotlessanchor system that allows the surgeon to establish the graft position,and, while maintaining that position, place the anchor without changingthe suture tension or causing a shift in the graft position due tosuture spin. Furthermore, if the anchor is threaded, placement of theanchor in the socket must occur without spinning of the suture.

If a graft such as a biceps tendon is directly affixed to a bone byinsertion of the graft into a socket (a technique referred to in the artas “bio-tenodesis”), it is essential that the graft be fully inserted soas to be engaged by the full length of the implant. It is also importantthat the position of the graft be maintained during anchor insertion.Further, it is essential that the alignment of the implant (referred toin this case as an “interference screw”) be coaxial, or if slightlyshifted, parallel to the axis of the socket. It is also desirable thatthe sutures used to draw the graft into the socket do not spin or twistduring anchor placement as this may change the position and tension ofthe graft from that intended by the surgeon. In sum, there is a alsoneed in the suture arts for an interference screw and implant placementsystem in which graft position within the socket is maintainedthroughout the implant placement process, and in which suture spin ortwisting is prevented.

Improved implant systems can also find utility in the context of spinalfusion surgery, wherein rigid posterior or lateral or anterior elements,either pedicle based, interbody based, or vertebral body based, orposterior element based, are routinely performed, by the placement ofscrews into the bony spinal elements and, through either internalmechanisms or rigid bridging devices, engage into adjacent bony elementsor interspaced to provide rigid fixation. Illustrative examples ofcommercially available spinal fixation devices include, for example,Synthes (Raynham, Mass.), Nuvasive (San Diego, Calif.) and Amendia(Atlanta, Ga.), devices that interlock cervical, thoracic or lumbar orsacral levels to rigidly prevent movement and fuse or allow for fusionof diseased or degenerated segments of spine to prevent painful ordisabling movement. These rigid zones of fixation create zones above andbelow these constructs, which are known as junctional or transitionalzones or levels. There is need in the art for a bracing mechanism thatcan disperse load from the rigidly fixed spinal segments havingundergone prior fusion or fixation, to unfused adjacent spinal segments.Such a bracing device, while not providing absolute rigid fixation butallowing for movement, would provide for bracing of the non fusedsegments while off-loading or reducing the forces that, prior to theapplication of such a device, would have been entirely borne by theintervertebral discs and adjacent bony elements and ligaments adjacentto the prior rigid fixed segments. It is this increased force that ispostulated to result in failure of the adjacent segment.

Suitable bracing devices can be inserted either along the anterioraspect of the spinal segments, the posterior aspect of the spinalsegments, or between spinal segments. Between these anchor devices andthe spinal segments or between the fusion devices and spinal segments,or bridging these spinal segments and fusion devices to intact spinalsegments, either soft tissue in the form of grafts, or with braidedsuture constructs, or with a combination thereof, bone anchors areutilized to insert these tension bearing or tension off loadingconstructs. Such tension-bearing constructs serve to provide a dynamicrather that rigid transition from the fused spinal segments to theadjacent spinal segments. The purposes of theses constructs are toreduce the load applied to the intervertebral discs above and below thefused spinal segments. This transitional loading allows the adjacentmusculature to recover following spinal fusion surgery while protectingthe discs until the muscle has recovered sufficiently, while alsoallowing needed movement at the transitional levels so as to not havecreated another static or rigidly fixed level. In addition, suchconstructs can be utilized to reconstruct spinal ligaments. Suchreconstructions can be performed either independent of, or in additionto rigid spinal fixation or along with intervertebral body discreplacements to help restore normal spinal segment mobility and preserveor protect the constructs.

SUMMARY OF THE INVENTION

A primary objective of the present invention is to provide improvedmeans and methods of attaching soft tissues (i.e., “grafts”) to bone insitu. The embodiments of the instant invention are described hereinbelowas a system and method for producing a matrix of implants for theanchoring of a graft to bone. Any graft fixation system which uses animplant placement system with an optionally cannulated non-rotatingtensioning device (i.e., the relatively fixed “inner assembly”)positioned within a cannulation or “lumen” of a cannulated driver (i.e.,the relatively movable “outer assembly”) to tension sutures in aprepared socket for the placement of a simple one-piece cannulatedanchor are contemplated by the present invention. Illustrative aspectsand embodiments of the present invention in accordance with theforegoing objective are as follows:

In a first aspect, the present invention provides prosthetic implantsand systems for their placement in a target boney surface for theknotless securing of a soft tissue graft thereto. The instant inventioncontemplates a novel placement system including a non-rotatingcannulated tensioning device (“inner assembly”) positioned within arotationally and axially movable cannulated driver (“outer assembly”).In a preferred embodiment, a tubular distal element of the tensioningdevice extends distally beyond the distal end of the cannulated driver.A cannulated threaded implant (or “anchor”) is removably mounted to thetorque-transmitting distal portion of the driver. Sutures placed in thegraft are drawn into the distal end of the elongate distal portion ofthe cannulated tensioning device, which extends beyond the distal end ofthe implant. If a threaded implant is used, the distal end of thecannulated driver preferably includes torque-transmitting features that,together with complementary features formed in the proximal portion ofthe implant or anchor, allow the transmission of torque thereto. If aninterference plug-type anchor is used, the distal end of the driver ispreferably configured to transmit axial force to the anchor, theproximal end of which has a suitably complementary configuration toenable secure attachment.

In operation, sutures placed in the graft are drawn into the distal endof the tensioning device. The elongate distal portion of tensioningdevice is inserted into a properly prepared socket in the target boneysurface so that the distal end of the tensioning device, with itssutures is positioned at the bottom of the socket. Tension is thenapplied to the sutures by pulling on their proximal ends, which extendbeyond the proximal portion of the tensioning device to move the graftinto the desired position, namely into the prepared socket adjacent tothe distal element of the tensioning device. The desired tension may bemaintained by cleating proximal portions of the suture(s) into slotsoptionally formed in the handle of the tensioning device. The anchor (orinterference screw) may then be screwed, threaded or otherwise driveninto the socket, thereby trapping the sutures or graft between theanchor exterior surface and the socket wall. Critically, twisting of thesuture(s) or graft(s) is prevented by the non-rotating distal tubularportion of the tensioning device that remains distal to the anchordistal end during anchor placement. In addition, tension on the suturesand the position of the graft are maintained during placement of theanchor throughout the procedure. After anchor placement, the driver andtensioning device are withdrawn, removed from the site, at which pointthe sutures may be trimmed to complete the procedure.

In contrast to the Burkhart and ElAttrache anchor systems, suturetensioning and establishment of the graft position are not accomplishedusing the driver's distal end or using an implant positioned in thedriver's distal end. Rather, suture tension and graft position areestablished and maintained by the distal portion of a non-rotatingtensioning device that extends beyond the driver and anchor distal ends.Because of this, the transmission of torque to the sutures and/or graftby the driver present in the Burkhart and ElAttrache systems iseliminated, along with its associated suture or graft spin.

The system and method of the instant invention provide a simplificationover other currently available anchoring methods and hardware in thatfewer steps are required and moreover the anchor has a simple,single-piece construction. The anchor system is scalable and, due to itssimple construction, may be used with anchors smaller than thosepermitted using other currently available systems. The composition andconstruction in the anchor may be readily modified simply by changingthe material from which it is constructed, by increasing or reducing thediameter or length of the anchor, by increasing or decreasing the wallthickness of the anchor, by modifying the profile of the exterior, or byany combination of these means. All such modifications are contemplatedas within the scope of the present invention.

In another aspect, the present invention provides a method for affixinga soft tissue graft to a target boney surface, the method including thesteps of:

-   -   a. providing a placement system having a cannulated non-rotating        tensioning device (“inner assembly”) and a cannulated driver        device (“outer assembly”), wherein the tensioning device is        positioned within the cannulation or “lumen” of the driver        device,    -   b. positioning a cannulated anchor onto the distal        torque-transmitting portion of the driver, over a distally        extending element of the tensioning device,    -   c. producing a suitably configured hole (i.e., “socket”) in a        prepared boney surface at a desired target location using a        drill, tap, punch or equivalent hole-producing device,    -   d. drawing sutures from the graft into the lumen of the        tensioning device,    -   e. inserting the distal end of the tensioning device into the        socket,    -   f. applying tension to the sutures to draw the graft to a        desired position,    -   g. placing the anchor (or interference screw) in the socket,    -   h. withdrawing the placement system,    -   i. trimming the suture tails, and    -   j. optionally repeating steps (c) through (i) as required.

In an alternate embodiment of the present invention, identical in allaspects to the previous embodiment except as subsequently described, thetubular distal portion of the tensioning device is replaced by a rodhaving formed at its distal end a sharpened fork portion. Two (or more)parallel, axially extending tines form the fork, the tines being spacedapart so that sutures may slide freely through the channel(s) formedbetween the tines. An anchor placement system commensurate with such anembodiment is used in the following manner: First, a cannulated threadedimplant is removably mounted to the torque-transmitting distal portionof the driver. Sutures placed in the graft are then positioned in thechannel(s) of the distal fork portion of the tensioning device. Theelongate distal portion of the tensioning device with the suturespositioned within its distal channel is then inserted into a preparedsocket so that the distal end of the tensioning device with its suturesis positioned at the bottom of the socket. Tension is then applied tothe sutures by pulling on their proximal ends to draw the graft into thedesired position. The desired tension and graft position may bemaintained by cleating the suture proximal portions in slots optionallyformed in the handle of the tensioning device. The anchor is thenscrewed, threaded or otherwise axially driven into the socket by thedriver, thereby trapping the sutures or graft between the anchorexterior surface and the socket wall. Twisting of the sutures or graftis prevented by the non-rotating distal fork portion of the tensioningdevice that remains distal to the anchor distal end during anchorplacement. The tension on the sutures and the position of the graft aremaintained during placement of the anchor. After anchor placement, thedriver and tensioning device are removed from the site and the suturestrimmed to complete the procedure.

In certain embodiments particularly applicable to small diameterimplants, the tensioning device may be cannulated and coupled with anelongate element formed from a suitable shape memory metal and/orsuperelastic polymeric material that, in a first configuration, isprovided with a suture retention loop at its distal end. The distal endof the elongate element extends out of and distally away from the distalend of the cannulated tensioning device so as to be accessible to freesuture ends. In operation, one or more sutures are loaded into thedistal retention loop. The sutures are then tensioned and secured aspreviously described, through cooperation of the cannulated tensioningdevice, cannulated anchoring implant and torque-transmitting driverdevice. After the implant is properly placed, the elongate element maybe readily transformed into a second relatively linear configuration andaxially withdrawn from the tensioning lumen. As noted elsewhere, theelongate element may preferably take the form of a nitinol wire.

An anchor placement system of the present embodiment may also include amechanism for releasably preventing relative axial and rotationalmovement between the driver and the tensioning device, such meansoptionally positioned within the cannulation (or “lumen”) of the driver.In a first condition, used during tensioning of the suture, relativeaxial and rotational motion is of the driver relative to the tensioningdevice is prevented. In a second condition, used during placement of theanchor, the driver may be advanced axially on the tensioning device tobring the anchor to the socket, and rotated to screw the anchor into thesocket, with the tensioning device remaining stationery so as tomaintain suture tension and prevent twisting of the sutures.

In a particularly preferred embodiment, prevention of relative motion isprovided by a removable key having one or more protrusions, coupled withfeatures formed on the handles of the tensioning device and driver suchthat, when the features are in alignment, engagement by the one or moreprotrusions of the key prevents relative axial or rotational movementbetween the torque-transmitting driver and the tensioning device.Removal of the key allows the driver to be advanced distally and rotatedrelative to the tensioning device. Other embodiments are anticipated inwhich other means are used to releasably prevent relative motion.

Certain preferred embodiments of the present invention are configuredfor one-handed operation by the surgeon. In these embodiments, asuitable tensioning device is irremovably (i.e., permanently) affixed toand/or positioned within an associated driver device, the driver deviceis axially movable between a first proximal position and a second distalposition relative to the tensioning device. In the first proximalposition, the distal portion of the tensioning device extends distallybeyond the implant so as to allow tensioning of sutures and positioningof a graft as described previously herein as well as in relatedco-pending applications incorporated herein by reference. Advancing thedriver distally toward its second, distal position brings the implant tothe prepared socket in preparation for placement. Thereafter, theimplant is threaded or axially driven into the socket. Distal motion bythe driver relative to the tensioning device is resisted by a springwithin the driver handle. The spring tension is sufficient to ensurethat the distal end of the tensioning device remains in contact with thebottom of the socket to maintain graft position and to prevent rotationof the tensioning device during anchor placement.

In yet another aspect, like the previous in all other respects except assubsequently described, the suture attached to the graft is positionedwithin the distal fork and tensioned such that the proximal end of thegraft is adjacent to the fork, the tension being maintained by cleatingof the sutures on the tensioning device handle. The distal portion ofthe tensioning device with the graft is inserted into the preparedsocket. The anchor is then threaded or driven into the socket aspreviously described, thereby trapping the graft proximal portionbetween the anchor exterior surface and a first portion of the socketwall, and the attached sutures between the anchor exterior surface and asecond, laterally opposed portion of the socket wall.

In a variation of the previous aspect, the graft may be pierced by thesharpened distally extending members of the distal fork. The distalportion of the tensioning element with the graft is inserted into theprepared socket. Once again, the anchor is then threaded or driven intothe socket, thereby trapping the graft proximal portion between theanchor exterior surface and a portion of the socket wall.

In another variation of the previous aspect, the graft is pierced by thesharpened distally extending members of the distal fork a predetermineddistance from the graft distal end such that when the distal portion ofthe tensioning element with the graft is inserted into the preparedsocket, the proximal end of the graft protrudes above the opening of thesocket. The anchor is then threaded or driven into the socket, therebytrapping the graft proximal portion between the anchor exterior surfaceand first and second laterally opposed portions of the socket wall.

In still yet another aspect, identical in form to the devices andinsertion systems previously herein described, the tensioning device hasa proximal handle portion that is an assembly of first and second rigidelements with an elastic element positioned therebetween. Applying adistal force to a first rigid element of the handle of the tensioningdevice causes deflection of the elastic element proportional to thetension in the graft attached to the distal fork. This allows thepractitioner to measure the tension in the graft. By establishing thetension in the graft to a predetermined value prior to placement of theanchor, the tension may then be maintained at the predetermined valueduring anchor placement.

These and other aspects are accomplished in the invention hereindescribed, directed to a system and method for producing a matrix ofimplants for the anchoring of a graft to bone. Further objects andfeatures of the invention will become more fully apparent when thefollowing detailed description is read in conjunction with theaccompanying figures and examples. For example, any graft fixationsystem that uses a non-rotating inner member (tensioning device) and amovable outer member (driver) to tension sutures in a prepared socketfor the placement of a simple one-piece cannulated anchor falls withinthe scope of this invention. However, it is to be understood that boththe foregoing summary of the invention and the following detaileddescription are of a preferred embodiment, and not restrictive of theinvention or other alternate embodiments of the invention. Inparticular, while the invention is described herein with reference to anumber of specific embodiments, it will be appreciated that thedescription is illustrative of the invention and is not constructed aslimiting of the invention.

BRIEF DESCRIPTION OF THE FIGURES

Various aspects and applications of the present invention will becomeapparent to the skilled artisan upon consideration of the briefdescription of figures and the detailed description of the presentinvention and its preferred embodiments that follows:

FIG. 1A is a plan view of the cannulated driver and anchor of an implantplacement system of the present invention.

FIG. 1B is an expanded view of the distal portion of the objects of FIG.1A at location C.

FIG. 1C is a side elevational sectional view of the objects of FIG. 1Aat location A-A of FIG. 1A.

FIG. 2A is a perspective view of the objects of FIG. 1A.

FIG. 2B is an expanded view of the distal portion of the objects of FIG.2A at location B.

FIG. 3 is a plan view of the tensioning device of an implant placementsystem of the present invention.

FIG. 4 is an expanded sectional view of the tensioning device of FIG. 3at location A-A.

FIG. 5 is an expanded view of the proximal hub portion of the tensioningdevice of FIG. 3 at location A.

FIG. 6 is a side elevational view of the objects of FIG. 3.

FIG. 7 is an expanded view of the objects of FIG. 6 at location B.

FIG. 8 is a perspective view of the tensioning device of FIG. 3.

FIG. 9 is an expanded view of the objects of FIG. 8 at location C.

FIG. 10 is a side elevational view of a key for an implant placementsystem of the present invention.

FIG. 11 is a perspective view of the objects of FIG. 10.

FIG. 12 is an exploded view of the assembly of a first embodiment of animplant placement system of the present invention.

FIG. 13 is a plan view of a fully assembled first embodiment of animplant placement system of the instant invention.

FIG. 14 is an expanded view of the distal portion of FIG. 13 at locationA.

FIG. 15 is an expanded side elevational sectional view of the objects ofFIG. 13 at location A-A.

FIG. 16 is a side elevational view of the objects of FIG. 13.

FIG. 17 is an expanded view of the objects of FIG. 13 at location B.

FIG. 18 is a perspective view of the objects of FIG. 13.

FIG. 19 is an expanded view of the objects of FIG. 13 at location C.

FIG. 20 is a perspective view of a first embodiment implant placementsystem with sutures being loaded into the system.

FIG. 21 is a perspective view of the first embodiment implant placementsystem with the sutures loaded.

FIG. 22 schematically depicts a socket placed in a bone prior to theplacement of an implant.

FIG. 23 depicts the first embodiment implant placement system positionedfor the first step of implant placement.

FIG. 24 depicts the proximal portion of the first embodiment implantplacement system during the first step of implant placement.

FIG. 25 depicts the distal portion of the first embodiment implantplacement system during the first step of implant placement.

FIG. 26 depicts the first embodiment implant placement system positionedfor the second step of implant placement.

FIG. 27 depicts the proximal portion of the embodiment implant placementsystem during the second step of implant placement.

FIG. 28 depicts the distal portion of the first embodiment implantplacement system during the second step of implant placement.

FIG. 29 depicts the first embodiment implant placement system positionedfor the third step of implant placement.

FIG. 30 depicts the proximal portion of the first embodiment implantplacement system during the second step of implant placement.

FIG. 31 depicts the distal portion of the first embodiment implantplacement system during the third step of implant placement.

FIG. 32 depicts the site at the completion of implant placement using animplant placement system of the instant invention.

FIG. 33 is a plan view of a second embodiment of an implant placementsystem of the instant invention wherein the tubular distal portion ofthe tensioning device is replaced by a rod having formed at its distalend a sharpened fork portion.

FIG. 34 is a side elevational view of the objects of FIG. 33.

FIG. 35 is an expanded proximal end view of the objects of FIG. 33.

FIG. 36 is an expanded plan view of the distal portion of the elementsof FIG. 33.

FIG. 37 is a side elevational view of the objects of FIG. 36.

FIG. 38 is a sectional view of the objects of FIG. 36 at location B-B.

FIG. 39 is a distal perspective view of the objects of FIG. 33.

FIG. 40 is an expanded view of the objects of FIG. 39 at location A.

FIG. 41 is a proximal perspective view of the objects of FIG. 33.

FIG. 42 is an expanded view of the objects of FIG. 41 at location B.

FIG. 43 depicts an alternate embodiment implant system of the presentinvention in use positioning sutures in a socket for the securing of agraft using an anchor.

FIG. 44 is an expanded view of the distal portion of the objects of FIG.43 depicting the placement site.

FIG. 45 depicts the alternate “fork” embodiment system with the suturestensioned so as to position the graft.

FIG. 46 is an expanded view of the distal portion of the objects of FIG.45 depicting the placement site.

FIG. 47 is an expanded view of the site depicting the system with theanchor placed.

FIG. 48 is an expanded view of the site at completion of the anchorplacement and removal of the system with the sutures trimmed.

FIG. 49 depicts a first step of an alternate repair method for securinga graft in a socket using an implant as contemplated by the presentinvention.

FIG. 50 depicts a second step of the alternate repair method

FIG. 51 depicts a third step of the alternate repair method.

FIG. 52 depicts the site of the graft attachment at the completion ofthe repair using the alternate repair method.

FIG. 53 depicts a first step of a second alternate repair method forsecuring a graft in a socket using an implant.

FIG. 54 depicts a second step of the alternate repair method

FIG. 55 depicts a third step of the alternate repair method.

FIG. 56 depicts a fourth step of the alternate repair method.

FIG. 57 depicts the site of the graft attachment at the completion ofthe repair using the alternate embodiment repair method.

FIG. 58 depicts a first step of a third alternate repair method forsecuring a graft in a socket using an implant.

FIG. 59 depicts a second step of the alternate repair method

FIG. 60 depicts a third step of the alternate repair method.

FIG. 61 depicts a fourth step of the alternate repair method.

FIG. 62 depicts a fifth step of the alternate repair method.

FIG. 63 depicts the site of the graft attachment at the completion ofthe repair using the alternate embodiment repair method.

FIG. 64 is a plan view of a distal assembly for the tensioning devicefor an alternate embodiment anchor placement system that includes aforce indicating inner tensioning assembly.

FIG. 65 is a side elevational view of the objects of FIG. 64.

FIG. 66 is a sectional view of the objects of FIG. 64 at location A-A.

FIG. 67 is an expanded proximal axial view of the objects of FIG. 64.

FIG. 68 is a perspective view of the objects of FIG. 64.

FIG. 69 is a expanded view of the proximal portion of the objects ofFIG. 68 at location A.

FIG. 70 is a plan view of the handle portion of a tensioning device foran alternate embodiment anchor placement system.

FIG. 71 is a side elevational view of the objects of FIG. 70.

FIG. 72 is a sectional view of the objects of FIG. 70 at location A-A.

FIG. 73 is a perspective view of the objects of FIG. 70.

FIG. 74 is an expanded proximal axial view of the objects of FIG. 70.

FIG. 75 is a perspective view of an end cap for the tensioning devicefor an alternate embodiment anchor placement system.

FIG. 76 is a plan view of the objects of FIG. 75.

FIG. 77 is a distal axial view of the objects of FIG. 75.

FIG. 78 is a side elevational view of the objects of FIG. 75.

FIG. 79 is a sectional view of the objects of FIG. 76 at location A-A.

FIG. 80 is a plan view of an alternate embodiment anchor placementsystem of the present invention that allows the surgeon to measure thetension in the graft during the attachment of the graft in accordancewith the methods of the present invention.

FIG. 81 is an expanded view of the proximal portion of the objects ofFIG. 80 at location A.

FIG. 82 is a perspective view of the objects of FIG. 80.

FIG. 83 is an expanded view of the proximal portion of the objects ofFIG. 82 at location A.

FIG. 84 is an central expanded side elevational sectional view of theobjects of FIG. 81.

FIG. 85 is a perspective view of the outer driver assembly for analternate embodiment implant placement system of the present invention.

FIG. 86 is a plan view of the driver of FIG. 85.

FIG. 87 is a side elevational view of the driver of FIG. 85.

FIG. 88 is a sectional view of the objects of FIG. 86 at location A-A.

FIG. 89 is a perspective view of the inner tensioning assembly for analternate embodiment implant placement system of the present invention.

FIG. 90 is a plan view of the objects of FIG. 89.

FIG. 91A is an expanded sectional view of the objects of FIG. 89 atlocation A-A.

FIG. 91B is an expanded view of the objects of FIG. 91A at location A.

FIG. 92 is a perspective view of a control element for an alternateembodiment implant placement system of the present invention.

FIG. 93 is a side elevational view of the control element of FIG. 92.

FIG. 94 is a perspective view of an exploded assembly of an alternateembodiment implant placement system comprising the outer driver assemblyof FIG. 85, the inner tensioning assembly of FIG. 89 and the controlelement of FIG. 92.

FIG. 95 is a perspective view of an alternate embodiment implantplacement system formed of the assembled elements of FIG. 94 with thedistal portion of the inner tensioning assembly protruding beyond theimplant in preparation for implant placement.

FIG. 96 is a plan view of the objects of FIG. 95.

FIG. 97 is a side elevational view of the elements of FIG. 95.

FIG. 98A is an expanded sectional view of the objects of FIG. 96 atlocation A-A.

FIG. 98B is an expanded view of the objects of FIG. 98A at location A.

FIG. 98C is an expanded view of the objects of FIG. 98B at location C.

FIG. 99 is an expanded sectional view of the objects of FIG. 96 atlocation D-D.

FIG. 100 is a perspective view of the anchor placement system of FIG. 95with the outer driver assembly and implant advanced distally as when theimplant is fully placed in a socket.

FIG. 101 is a plan view of the objects of FIG. 100.

FIG. 102 is a side elevational view of the objects of FIG. 100.

FIG. 103 is an expanded sectional view of the objects of FIG. 101 atlocation A-A.

FIG. 104 is an expanded sectional view of the objects of FIG. 101 atlocation D-D.

FIG. 105 is a perspective view of the exploded assembly of an alternateanchor placement system of the present invention.

FIG. 106A is a perspective view of an alternate embodiment anchorplacement system formed of the elements and assemblies of FIG. 105 withthe distal portion of the inner tensioning assembly extended beyond theimplant in preparation for anchor placement.

FIG. 106B is an expanded view of the objects of FIG. 106A at location A.

FIG. 107 is a plan view of the anchor placement system of FIG. 106.

FIG. 108 is a side elevational view of the objects of FIG. 106.

FIG. 109 is an expanded sectional view of the objects of FIG. 107 atlocation B-B.

FIG. 110 is an expanded sectional view of the objects of FIG. 107 atlocation A-A.

FIG. 111 is a perspective view of the anchor placement system of FIG.106 with the outer driver assembly and implant advanced on the innertensioning assembly as when an implant is fully placed in a socket.

FIG. 112 is a plan view of the objects of FIG. 111.

FIG. 113 is a side elevational view of the objects of FIG. 111.

FIG. 114 is an expanded sectional view of the objects of FIG. 112 atlocation B-B.

FIG. 115 is an expanded sectional view of the objects of FIG. 112 atlocation A-A.

FIG. 116 is a perspective view of the exploded assembly of an alternateembodiment implant placement system of the present invention.

FIG. 117 is a perspective view of an alternate embodiment implantplacement system of the present invention formed from the elements andassemblies of FIG. 116 with the distal portion of the inner tensioningassembly protruding beyond the implant in preparation for implantplacement.

FIG. 118 is a plan view of the objects of FIG. 117.

FIG. 119 is a side elevational view of the objects of FIG. 117.

FIG. 120 is an expanded sectional view of the objects of FIG. 118 atlocation B-B.

FIG. 121 is an expanded sectional view of the objects of FIG. 118 atlocation A-A.

FIG. 122 is a perspective view of the anchor placement system of FIG.117 with the outer driver assembly and implant advanced on the innertensioning assembly as when an implant is fully place in a socket.

FIG. 123 is a plan view of the objects of FIG. 122.

FIG. 124 is a side elevational view of the objects of FIG. 122.

FIG. 125 is an expanded sectional view of the objects of FIG. 123 atlocation A-A.

FIG. 126 is an expanded sectional view of the objects of FIG. 123 atlocation B-B.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Aspects of the present invention relate to and/or overlap with aspectsdescribed in related co-pending and contemporaneously filed applicationsentitled “Ceramic Implant Placement Systems And Superelastic SutureRetention Loops For Use Therewith” Ser. No. 15/256,815 and “MultipleImplant Constructions And Fixation Methods Associated Therewith” Ser.No. 15/256,945, the entire contents of which are hereby incorporated intheir entirety.

Although any methods and materials similar or equivalent to thosedescribed herein can be used in the practice or testing of embodimentsof the present invention, the preferred methods, devices, and materialsare now described. However, before the present materials and methods aredescribed, it is to be understood that the present invention is notlimited to the particular sizes, shapes, dimensions, materials,methodologies, protocols, etc. described herein, as these may vary inaccordance with routine experimentation and optimization. It is also tobe understood that the terminology used in the description is for thepurpose of describing the particular versions or embodiments only, andis not intended to limit the scope of the present invention which willbe limited only by the appended claims. Accordingly, unless otherwisedefined, all technical and scientific terms used herein have the samemeaning as commonly understood by one of ordinary skill in the art towhich the present invention belongs. However, in case of conflict, thepresent specification, including definitions below, will control.

In the context of the present invention, the following definitionsapply:

The words “a”, “an” and “the” as used herein mean “at least one” unlessotherwise specifically indicated. Thus, for example, reference to an“opening” is a reference to one or more openings and equivalents thereofknown to those skilled in the art, and so forth.

The term “proximal” as used herein refers to that end or portion whichis situated closest to the user of the device, farthest away from thetarget surgical site. In the context of the present invention, theproximal end of the implant system of the present invention includes thedriver and handle portions.

The term “distal” as used herein refers to that end or portion situatedfarthest away from the user of the device, closest to the targetsurgical site. In the context of the present invention, the distal endof the implant systems of the present invention includes componentsadapted to fit within the pre-formed implant-receiving socket.

In the context of the present invention, the terms “cannula” and“cannulated” are used to generically refer to the family of rigid orflexible, typically elongate lumened surgical instruments thatfacilitate access across tissue to an internally located surgery site.

The terms “tube” and “tubular” are interchangeably used herein to referto a generally round, long, hollow component having at least one centralopening often referred to as a “lumen”.

The terms “lengthwise” and “axial” as used interchangeably herein torefer to the direction relating to or parallel with the longitudinalaxis of a device. The term “transverse” as used herein refers to thedirection lying or extending across or perpendicular to the longitudinalaxis of a device.

The term “lateral” pertains to the side and, as used herein, refers tomotion, movement, or materials that are situated at, proceeding from, ordirected to a side of a device.

The term “medial” pertains to the middle, and as used herein, refers tomotion, movement or materials that are situated in the middle, inparticular situated near the median plane or the midline of the deviceor subset component thereof.

As discussed above, when a tissue, more particularly a soft connectivetissue in a joint space, becomes damaged or torn from its associatedbone or cartilage, surgery is usually required to reattach the tissue orreconstruct the bone. The present invention is directed to various meansand mechanisms for securing the displaced tissue to boney tissue.

As used herein, the term “tissue” refers to biological tissues,generally defined as a collection of interconnected cells that perform asimilar function within an organism. Four basic types of tissue arefound in the bodies of all animals, including the human body and lowermulticellular organisms such as insects, including epithelium,connective tissue, muscle tissue, and nervous tissue. These tissues makeup all the organs, structures and other body contents. While the presentinvention is not restricted to any particular soft tissue, aspects ofthe present invention find particular utility in the repair ofconnective tissues such as ligaments or tendons, particularly those ofthe shoulder, elbow, knee or ankle joint.

In a similar fashion, while the present invention is not restricted toany particular boney tissue, a term used herein to refer to both bonesand cartilage, aspects of the present invention find particular utilityin the repair or reattachment of connective tissues to the boneyelements of the shoulder, elbow, knee or ankle joint.

When the damaged tissue is of sufficient quantity and quality, thedamaged portion may simply be directly reattached to the bone from whichit was torn so that healing back to the bone can take place. However, inother situations, a “graft” may be needed to stimulate regrowth andpermanent attachment. In the context of the present invention, the term“graft” refers to any biological or artificial tissue being attached tothe boney tissue of interest, including:

-   -   Autografts, i.e., grafts taken from one part of the body of an        individual and transplanted onto another site in the same        individual, e.g., ligament graft;    -   Isografts, i.e., grafts taken from one individual and placed on        another individual of the same genetic constitution, e.g.,        grafts between identical twins;    -   Allografts, i.e., grafts taken from one individual placed on        genetically non-identical member of the same species; and    -   Xenografts, i.e., grafts taken from one individual placed on an        individual belonging to another species, e.g., animal to man.

Autografts and isografts are usually not considered as foreign and,therefore, do not elicit rejection. Allografts and xenografts arerecognized as foreign by the recipient thus carry a high risk ofrejection. For this reason, autographs and isografts are most preferredin the context of the present invention.

Surgical interventions such as contemplated herein generally require theboney tissue to be prepared for receiving the graft. In the context ofthe present invention, such preparation includes the formation of a“socket”, i.e., a hole punched or drilled into the bone into which aprosthetic device such as an implant may be received. The socket may beprepared at the desired target location using conventional instrumentssuch as drills, taps, punches or equivalent hole-producing devices.

While certain procedures contemplate directly attaching the graft to thebone, the more common route involves the employment of an implantspecially configured to hold and/or enable attachment of the graft tothe boney tissue. As used herein, the term “implant” refers to aprosthetic device fabricated from a biocompatible and/or inert material.In the context of the present invention, examples of such “implants”include conventional and knotless anchors of both the screw-threaded andinterference-fit variety.

In certain embodiments, the present invention contemplates fabricationof the implant from either a metallic material or a suitable polymericmaterial, including, but not limited to, polyetheretherketone (PEEK), apolymeric composite such as, for instance, carbon fiber reinforced PEEK(PEEK CF), or of a suitable bioabsorbable material such as, forinstance, polylactic acid (PLA). The present invention also contemplatesthe use of very small knotless anchors produced from ceramic materialsusing a process known as “Ceramic Injection Molding” or simply “CIM”.The tensile strength of PEEK material is typically between 10,000 and15,000 psi. In comparison, the tensile strength of alumina is generallyin excess of 200,000 psi. Furthermore, recently developed materials suchas Zirconia Toughened Alumina (ZTA) by Coorstek Inc. (Golden, Colo.)have a high degree of toughness in addition to high tensile strength.These materials, being ceramic, do not have a yield point and thereforedo not deform under load. The high tensile strength and the absence ofyielding under load of an implant constructed of such ceramic materialsallow torque to be transmitted to the implant through features that arenot producible by the machining of metal or that would fail in use ifformed from a polymeric material such as PEEK.

In certain embodiments, the implant may take the form of a ceramicinterference plug, wherein the high elastic modulus and high strength ofthe ceramic materials is beneficial for small and miniature interferencetype anchors that are driven axially into a prepared socket. The highmodulus and high strength of the materials allows the thickness of thewall between the central lumen and the outer surface to be reducedcompared to interference type anchors produced from polymeric materialswithout reducing the compressive force which retains the one or moresutures between the outer wall of the implant and the wall of thesocket.

The preferred implant system of the present invention is comprised of anoptionally cannulated tensioning device (also referred to as the“inserter” or “insertion device”) slidably received within the lumen ofa cannulated driver device (also referred to as the implant driver) thattogether serve to tension sutures in a prepared socket for the placementof a simple one-piece cannulated anchor. In the Examples below, thepresent invention makes reference to various lock-and-key type matingmechanisms that serve to establish and secure the axial and rotationalarrangement of these device components. It will again be readilyunderstood by the skilled artisan that the position of the respectivecoordinating elements (e.g., recessed slots and grooves that mate withassorted projecting protrusions, protuberances, tabs and splines) may beexchanged and/or reversed as needed.

The implant placement system of the present invention requires a robustconnection between the “driver device” and the associated “implant” or“anchor” so as to ensure that the two rotate as a single unit such thatrotational force or “torque” applied to the proximal end of the system(e.g., via the proximal handle portion of the driver device) istransmitted to the distal end of the system (e.g., the distal end of theimplant disposed in the prepared socket) without incident orinterruption. This continuous “torque transfer” along the length of thesystem, from proximal to distal end, is critical to the function of thedriver, enabling it to distally advance the implant and firmly securethe implant (and any associated sutures or tissues) in the biologicalsite of interest. In the context of the present invention, thiscontinuous torque transfer is achieved by means of coordinating“torque-transmitting” elements, namely a distal “torque-transmittingportion” of the driver device that is configured to mate with and/orconform to a “torque-transmitting” (or alternatively “torque-receiving”or “torque-transferring”) portion of the implant, such “portion”including at a minimum the proximal end of the implant though thepresent invention contemplates embodiments where “torque-transmitting”features on the implant extend along the length of the implant. Therespective “torque-transmitting” features on the driver device andimplant cooperate to ensure that any proximal torque applied by the userto the proximal handle portion of the device is directly conveyed(“transmitted”) to the distal end of the implant.

In certain embodiments, the torque-transmitting portion of the implantmay take the form of a laterally extending slot in the proximal end ofthe implant similar to a standard screwdriver slot; however, othergeometries are contemplated and described in detail herein as well as indisclosures incorporated by reference herein. In addition, like theimplant itself, the distal torque-transmitting portion of the driver mayalso be fabricated from a ceramic material and formed by ceramicinjection molding so as to allow miniaturization of thetorque-transmitting features.

The present invention makes reference to insertion devices commonlyreferred to in the art as “drills” and “drivers”, i.e., devices that“drill” the socket and “drive” the implant into the socket. In thecontext of the present invention, the drills and drivers may beconventional, e.g., rigidly linear as previously herein described, or,as discussed in detail herein, “off-axis”, e.g., having an angularlyoffset distal portion adapted to drill off-axis sockets in boney tissuesthat are remote and difficult to access and drive therein thecorresponding implant, such as an anchor or interference screw.

The present invention contemplates securing the graft to the implant viasutures. In the context of the present invention, the term “suture”refers to a thread-like strand or fiber used to hold body tissues aftersurgery. Sutures of different shapes, sizes, and thread materials areknown in the art and the present invention is not restricted to anyparticular suture type. Accordingly, in the context of the presentinvention, the suture may be natural or synthetic, monofilament ormultifilament, braided or woven, permanent or resorbable, withoutdeparting from the spirit of the invention.

In certain embodiments, the present invention makes reference to anelongate element of a superelastic and/or shape memory materialconfigured to include a suture retention loop at its distal end anddesigned to be slidably received within a lumen of a cannulatedtensioning device or inserter. In certain preferred examples, theelongate element takes the form of a “nitinol wire”. In the context ofthe present invention, “nitinol” is a super elastic metal alloy ofnickel and titanium. In a preferred embodiment, the two elements arepresent in roughly equal atomic percentage (e.g., Nitinol 55, Nitinol60). Nitinol alloys exhibit two closely related and unique properties:shape memory effect (SME) and superelasticity (SE; also calledpseudoelasticity, PE). Shape memory is the ability of nitinol to undergodeformation at one temperature, then recover its original, undeformedshape upon heating above its “transformation temperature”.Superelasticity occurs at a narrow temperature range just above itstransformation temperature; in this case, no heating is necessary tocause the undeformed shape to recover, and the material exhibitsenormous elasticity, some 10-30 times that of ordinary metal.

The present invention also makes reference to high strength polymericmaterials and high tensile strength ceramic materials, such as aluminaor zirconia, that may be formed to complex shapes by a process referredto as Ceramic Injection Molding (CIM). In this process, ceramic powderand a binder material are molded to a shape that is subsequently firedin a furnace to eliminate the binder material and sinter the ceramicpowder. During this sintering operation the item is reduced in size bytwenty to thirty percent and achieves near 100% density with very highdimensional repeatability. Ceramic materials that are routinely moldedand thus contemplated by the present invention include, but are notlimited to, alumina, zirconia toughened alumina (ZTA) and partiallystabilized zirconia (PSZ). The flexular strengths of these materialsrange from 55,000 psi to 250,000 psi, far higher than the 25,000 psiflexular strength of implantable PEEK material.

The instant invention has both human medical and veterinaryapplications. Accordingly, the terms “subject” and “patient” are usedinterchangeably herein to refer to the person or animal being treated orexamined. Exemplary animals include house pets, farm animals, and zooanimals. In a preferred embodiment, the subject is a mammal, morepreferably a human.

Hereinafter, the present invention is described in more detail byreference to the Figures and Examples. However, the following materials,methods, figures, and examples only illustrate aspects of the inventionand are in no way intended to limit the scope of the present invention.For example, while the present invention makes specific reference toarthroscopic procedures, it is readily apparent that the teachings ofthe present invention may be applied to other minimally invasiveprocedures and are not limited to arthroscopic uses alone. As such,methods and materials similar or equivalent to those described hereincan be used in the practice or testing of the present invention.

EXAMPLES

The present invention attempts to address these afore-noted problems inthe art. To that end, FIGS. 1A through 1C and 2A and 2B depict acannulated driver 1500 for a knotless anchor system of the instantinvention. Driver 1500 has a proximal handle 1502 in which is formed aproximal cylindrical recess 1504, and off-axis lateral holes 1506, and atubular distal portion 1510 having at its distal end tubular driveelement 1512. The distal portion 1514 of drive element 1512 isconfigured to be complementary to internal drive features 1602 in theproximal portion of the lumen of cannulated threaded anchor 1600;accordingly, torque supplied by driver 1500 is transmitted to anchor1600. The distal portion of drive element 1512 may be fabricated in avariety of sizes, shapes, configurations and lumen sizes to suit avariety of anchors 1600, the requirements for a particular anchor 1600depending on its size, configuration and material properties. Forexample, the complementary drive elements may take the form of aninternally or externally positioned hexagonal or square drive, aninternal or external spline, or slots positioned internal or external tothe anchor. However, the present invention contemplates alternatecooperating configurations and thus is not limited to any one particularembodiment.

Referring now to FIGS. 3 through 9, cannulated tensioning device 1400has a proximal hub 1402 with a distal cylindrical portion 1404 in whichare formed off-axis lateral grooves 1406, and cleats 1408 formed in theproximal rim of proximal hub 1402. Tensioning device 1400 has a tubularmiddle portion 1410, and a tubular distal portion 1412, distal portion1412 having a diameter 1414 and length 1416. Diameter 1414 is selectedsuch that distal portion 1412 may be slidably positioned within distaldrive element 1512 of cannulated driver 1500. Length 1416 is determinedsuch that when tensioning device 1400 is positioned within the lumen ofthe cannulated driver 1500, distal portion 1412 of tensioning device1400 protrudes beyond distal drive element 1512 of driver 1500 asufficient distance so that when anchor 1600 is mounted on distal driveelement 1512 and distal portion 1412 is inserted to the full depth of asuitable socket formed in bone, anchor 1600 is still proximal to andclear of the socket. Elongate wire element 1302 having at its distal endloop 1304 and at its proximal end polymeric element 1306 forming a pulltab forms a loading loop 1300 for drawing sutures into the lumens oftubular members 1410 and 1412.

FIGS. 10 and 11 depict an illustrative embodiment of removable key 1200that may serve to prevent relative axial and rotational movement betweenthe cannulated driver and the tensioning device. In this embodiment, key1200 has a planar portion 1202 and cylindrical portions 1204 that aresized and spaced such that cylindrical portions 1204 may be insertedinto off-axis lateral holes 1506 of handle 1502 of cannulated driver1500.

FIG. 12 depicts cannulated driver 1500 with anchor 1600 loaded thereto,tensioning device 1400 with loading loop 1300 positioned for loading asuture, and key 1200 prior to mounting of driver 1500 to tensioningdevice 1400 in preparation for use. When driver 1500 is mounted totensioning device 1400, off-axis slots 1406 of handle 1402 of tensioningdevice 1400 are aligned with off-axis holes 1506 of handle 1502 ofdriver 1500 and cylindrical portions 1204 of key 1200 are inserted intothe passages so formed. Positioning of key 1200 in this manner preventsaxial and rotational movement of tensioning device 1400 relative todriver 1500. FIGS. 13 through 19 depict knotless suture anchor system1000 of the instant invention prepared for use with key 1200 and loadingloop 1300 in place.

Sutures 1800 are loaded into system 1000 by placing the proximal ends ofsutures 1800 in distal loop 1304 of loading loop 1300 as depicted inFIG. 20. Tab 1306 of loading loop 1300 is withdrawn proximally untilproximal ends 1802 of sutures 1800 extend proximally beyond hub 1402 oftensioning device 1400 as depicted in FIG. 21.

The present invention may be used to secure any type of soft tissue,graft, or tendon, such as, for example, a biceps tendon or a rotatorcuff. An illustrative method of fixation according to the principles ofthe instant invention is depicted in FIGS. 22 through 32. FIG. 22schematically depicts a socket 32 formed by drilling or punching in bone30, and a graft 20 to be affixed to bone 30. Sutures 1800 are passedthrough graft 20 in a usual manner; and the sutures loaded into system1000 as previously described and depicted in FIGS. 20 and 21, such thatsuture proximal ends 1802 are accessible to the surgeon. Subsequently,distal tubular portion 1412 of tensioning device 1400 is inserted intosocket 32 as depicted in FIGS. 23 through 25, the distal end of tubularportion 1412 contacting the bottom surface of socket 32. Thereafter,referring to FIGS. 26 through 28, the surgeon grasps proximal ends 1802of sutures 1800 and withdraws them proximally so as to advance graft 20towards socket 32. When graft 20 is in the desired position, proximalends 1802 of sutures 1800 are secured in cleats 1408 to maintain thegraft position. So long as proximal ends 1802 of sutures 1800 remainsecurely cleated and the distal end of tubular element 1412 ismaintained in contact with the bottom surface of socket 32, the positionof graft 20 will not change. The surgeon may adjust sutures 1800 asrequired to achieve optimal placement of graft 20. When this optimalplacement of graft 20 has been achieved, while maintaining contactbetween the distal end off distal tubular element 1412 and the bottom ofsocket 32, the surgeon removes key 1200 from system 1000 so as to allowaxial and rotational movement of driver 1500. The surgeon then advancesanchor 1600 to socket 32 and screws the anchor into socket 32 so as totrap sutures 1800 between anchor 1600 and the wall of socket 32 in bone30 as depicted in FIGS. 29 through 31. When anchor 1600 is fullyinserted in socket 32, proximal ends 1802 of sutures 1800 are releasedfrom cleats 1408 and system 1000 is withdrawn from the joint, leavingthe repair site as depicted in FIG. 32. Subsequently sutures 1800 arecut adjacent to anchor 1600 and the anchor placement is complete.

In an alternate method for anchor placement according to the presentinvention, the process may be simplified through use of an alternateembodiment system of the present invention in which the sutures are notdrawn into a cannulation of the tensioning device, but rather arepositioned and retained within a forked portion formed at the distal endof the tensioning device. In this alternate embodiment, sutures do notenter the lumen of the cannulated anchor, but rather wrap around thedistal end of the anchor during insertion and are retained in place byfriction between the external surfaces of the anchor and the boneysurface of the socket at laterally opposed locations.

Alternate embodiment anchor placement system 2000, depicted in FIGS. 33through 42, is identical to system 1000 in all aspects except asspecifically subsequently described. Specifically, cannulated distaltubular element 1412 of system 1000 is replaced by distal element 2442that is not cannulated and has formed at its distal end elongatelaterally opposed, distally extending portions 2444 with sharpeneddistal ends 2448. Elongate portions 2444 form the tines of a fork withchannel 2446 formed between portions 2444. Tensioning device handle 2402has formed near the distal end of its external surface flanges 2430wherein are formed slots 2432 which serve as cleats for maintaining thetension of sutures placed therein, flanges 2430 and slots 2432 replacingslots 1408 in hub 1402 of system 1000.

A method of fixation according to the principles of the instantinvention using system 2000 is depicted in FIGS. 43 through 48. A socket2032 is formed by drilling or punching in bone 2030. Sutures 2800 arepassed through graft 2020 in a usual manner. Sutures 2800 are positionedwithin channel 2446 at the distal end of distal element 2442 of thetensioning device and distal element 2442 is inserted into socket 2032such that the distal end of elongate portions 2444 contact the bottom ofthe socket as depicted in FIGS. 43 and 44. Thereafter, referring toFIGS. 45 and 46, the surgeon grasps proximal ends 2802 of sutures 2800and withdraws them proximally so as to advance graft 2020 towards socket2032. When graft 2020 is in the desired position, proximal ends 2802 ofsutures 2800 are secured in cleats 2432 in flanges 2430 of handle 2402to maintain the graft position. So long as proximal portions 2802 ofsutures 2800 remain cleated and the distal end of distal tensioningelement 2442 is maintained in contact with the bottom surface of socket2032, the position of graft 2020 will not change. The surgeon may adjustsutures 2800 as required to achieve optimal placement of graft 2020.When this optimal placement of graft 2020 has been achieved, whilemaintaining contact between the distal end off distal tubular element2442 and the bottom of socket 2032, the surgeon removes key 2200 fromsystem 2000 so as to allow axial and rotational movement of the driverassembly. The surgeon advances anchor 2600 to socket 2032 and screws theanchor into socket 2032 so as to trap sutures 2800 between anchor 2600and the walls of socket 2032 in bone 2030 as depicted in FIG. 47. Whenanchor 2600 is fully inserted in socket 2032, proximal portions 2802 ofsutures 2800 are released from cleats 2432 and system 2000 is withdrawnfrom the joint. Subsequently suture proximal portions 2802 of sutures2800 are cut adjacent to anchor 2600 and the anchor placement iscomplete. The position of the graft is maintained by friction betweenthe sutures 2800 that are trapped between the exterior surface of anchor2600 and two laterally opposed portions of the walls of socket 2032.

Anchor placement systems of the present invention are also useful forthe attachment of tendons in a procedure called bio-tenodesis. Whenattaching, for instance, a biceps tendon to the humeral shaft, theproximal end of the tendon is inserted into the socket and the implantplaced in a manner that traps the tendon between the anchor and the wallof the socket thereby retaining the tendon in the socket.

FIGS. 49 through 52 depict an alternate embodiment method for fixationof a tendon graft using system 2000. As is commonly done in preparationfor a bio-tenodesis type procedure, the portion of the graft that is tobe inserted into the socket is first sutured in a circumferentialmanner, the sutures providing added resistance to pull-out when therepair is completed. Excess suture from the circumferential suturing(also called “whip stitching”) is used to position the tendon prior toanchoring by the implant. Unlike previous embodiment methods disclosedherein, the positioning of graft 3020 is not achieved by tensioning thesutures after distal element 3442 is inserted into socket 3032. Rather,as depicted in FIG. 49 sutures 3802 are positioned within channel 3446at the distal end of distal element 3442 of the tensioning device andtensioned such that graft 3020 is positioned and retained adjacent tothe distal end of distal element 3442 adjacent to distally extendingportions 3444. Tension in sutures 3802 is then maintained by cleating inthe manner previously herein described. Thereafter, distal element 3444is inserted into socket 3032 as shown in FIG. 50 and anchor 3600 isplaced as depicted in FIG. 51 trapping graft 3020 between anchor 3600and the boney surface of the wall of socket 3032 at a first location,and trapping sutures 3082 between anchor 3600 and the boney surface ofthe wall of socket 3032 at a second location. Friction forces acting atthese locations maintain the position of graft 3020 relative to socket3032 and bone 3030. FIG. 52 depicts the site at completion of the anchorplacement and removal of insertion system 3000.

FIGS. 53 through 57 depict an alternate embodiment method of anchoring agraft to bone using the alternate anchor placement system 2000 of thepresent invention. Rather than using tensioned sutures to maintain theplacement of a graft at the distal end of distal element 3442 aspreviously depicted in FIG. 49, the graft is impaled on the distallyextending portions 3444 of distal element 3442 as shown in FIGS. 53 and54, the sharpened distal ends 3448 of extending portions 3444penetrating the graft. Thereafter, distal element 3444 is inserted intosocket 3032 as shown in FIG. 55 and anchor 3600 is placed as depicted inFIG. 56 trapping graft 3020 between anchor 3600 and the boney surface ofthe wall of socket 3032. Friction force between the inserted portion ofgraft 3020 and socket 3032 maintains the position of graft 3020 relativeto socket 3032 and bone 3030. FIG. 57 depicts the site at completion ofthe anchor placement and removal of insertion system 3000. If the grafthas been whip-stitched and the excess suture remains, the suture tailswill also be trapped between anchor 3600 and socket 3032 therebyproviding additional resistance to pull out.

FIGS. 58 through 63 depict yet another alternate method for securing aligament graft to bone using anchor system 2000. As in the previousembodiments, sutures are not used to position and tension the graft 3020in socket 3032. Rather, as in the previous method, graft 3020 is impaledon the distally extending portions 3444 of distal element 3442 as shownin FIGS. 58 and 59, the sharpened distal ends to of extending portions3444 penetrating the graft. The site for penetration is selected suchthat when the ligament is inserted to the bottom of socket 3032 theproximal end of graft 3020 protrudes above the rim of socket 3032. Asseen in FIG. 60, graft 3020 is positioned above socket 3032, inserted asshown in FIG. 61, and anchor 3600 placed as shown in FIG. 62. FIG. 63shows the completed repair. Graft 3020 is trapped between the exteriorsurface of anchor 3600 and first and second laterally opposed portionsof the wall of socket 3032 and retained in position by frictiontherefrom.

It may be useful to determine the tension in a tendon undergoing atenodesis procedure so that optimal tension may be selected based on theparticular anatomy. In another embodiment of the instant invention, theinner tensioning member is provided with a mechanism that indicates theforce being applied to the graft during insertion into the socket. Theinsertion site on the graft may be adjusted such that when the graft isinserted to the bottom of the socket the predetermined optimal tensionis achieved, and thereafter maintained during anchor placement.

FIGS. 64 through 69 depict a distal assembly 4401 for a force indicatingmechanism for use with an inner tensioning assembly in accordance withthe present invention. Elongate tubular element 4410 has at its distalend distal element 4442, identical to distal element 3442 (FIGS. 36through 40), and at its proximal end element 4450 affixed thereto.Element 4450 has a cylindrical outer surface portion 4452 and a planarouter surface portion 4454. The proximal end of tubular element 4410 isthen positioned within lumen 4456. Recess 4458 extends distally fromproximal-most surface 4451.

FIGS. 70 to 74 depict a handle 4402 for a force indicating innertensioning assembly. Handle 4402 is identical to handle 2402 in allaspects except as subsequently described. Specifically, handle 4402 hasa distal lumen 4491 with a diameter that allows tubular element 4410 tobe slidably positioned therein. Recess 4496 extends distally fromproximal-most surface 4403 of handle 4402 and has a cylindrical surfaceportion 4497 and a planar portion 4498 sized such that element 4450 maybe positioned therein. This construction is such that when distalassembly 4401 is assembled to handle 4402 with element 4450 positionedwithin recess 4496 and tubular member 4410 is positioned within lumen4491 of handle 4402, distal assembly 4401 may be move axially relativeto handle 4402 but rotation is prevented. Handle 4402 has a window 4490formed in its top surface with adjacent beveled surfaces 4492 so thatrecess 4496 and elements therein may be viewed.

FIGS. 75 through 79 depict a proximal end cap 4700 for handle 4402. Endcap 4700 has a distal portion 4702 with proximally extending recess4704, and a proximal portion 4706. Distal portion 4702 is configured forassembly to handle 4402.

Referring now to FIGS. 80 through 84 which depict a force-indicatinganchor system 4000 of the instant invention, distal assembly 4401 may beassembled to handle 4402 as previously described, and end cap 4700 isassembled to the proximal end of handle 4402. Spring 4900 is positionedtherebetween with its distal end in recess 4458 of element 4450 and itsproximal end in recess 4704 of end cap 4700. As seen in FIG. 81, indicia4470 are formed on beveled surfaces 4492 such that the position ofproximal-most surface 4451 of element 4450 visible through window 4490may be quantified. The position of element 4450 and its proximal-mostsurface 4451 is determined by the amount of deflection of spring 4900,which is in turn determined by the force exerted on distal assembly4401. This force is exerted on distal assembly 4401 by tension in thegraft during insertion into a socket by distal element 4442. Device 4000may be calibrated so that during insertion of the graft into the socketby the surgeon, by observing the position of proximal-most surface 4451relative to the indicia, will know the insertion force and thereby thetension in the graft.

When using embodiments previously herein described, the innermember/tensioning device is maintained in a non-rotating condition bythe surgeon's hand on the proximal hub of the tensioning device/innerassembly. The surgeon's hand on the proximal hub also maintains contactbetween the distal end of the tensioning device and the bottom of theprepared socket by applying distal force to the hub. To advance theouter assembly/driver and the implant removably mounted thereto to theprepared socket and to place the implant therein, the surgeon must firstuncouple the driver from the tensioning device, then move the driveraxially to position the implant at the socket, and must then screw theimplant into the socket. The requires the use of both of the surgeon'shands since when doing these actions with the driver, the surgeon mustmaintain the position of the tensioning device.

However, other embodiments of the present invention contemplateperformance of these functions with a single hand. For example, ratherthan being supplied by the surgeon's hand, the forward force on thetensioning member/inner assembly may alternatively be supplied by anelastic member that is part of the inner assembly. Rotation of the innertensioning assembly is prevented by contact between the distal end ofthe tensioning and the bottom surface of the prepared socket in whichthe implant is to be placed.

FIGS. 85 through 88 depict driver/outer assembly 5500 and implant 5600for an alternate embodiment implant placement system of the presentinvention configured for one-handed operation by a surgeon. Driver 5500and implant 5600 are identical in all aspects of form to driver 1500 andimplant 1600 (FIGS. 1 through 2B) except as hereafter specificallydescribed. For example, off-axis holes 1506 of handle 1502 of driver1500 are eliminated, as are the planar regions in which they intersect.Proximal cylindrical recess 5504 extends distally to intersect verticalcylindrical recess 5534 that is configured to receive a slidable controlelement, the upper portion of vertical recess 5534 being configured toreceive retainer 5530 with coaxial opening 5532.

Inner assembly 5400, depicted in FIGS. 89 through 91B, is identical inform to tensioning device/inner assembly 1400 depicted in FIGS. 3through 8 except as specifically hereafter described. For example, thedistal cylindrical portion 1404 with off-axis lateral grooves 1406 ofhub 1402 of tensioning device 1400 is eliminated. In its stead, innertensioning assembly 5400 has distally adjacent to hub 5402, assembly5450 formed of proximal element 5452 and distal element 5458 with spring5454 positioned therebetween as depicted in FIG. 91A. Proximal element5452 and distal element 5458 are rotatably and slidably positioned ontubular middle portion 5410. Positioned distal to distal element 5458and separated therefrom by washer 5462 (FIG. 91B), element 5456 isaffixed to tubular middle portion 5410. Element 5456 has a proximalportion 5476, a middle portion 5470 of reduced diameter forming acircumferential channel bounded by proximal wall 5466 and distal wall5468, and a distal portion 5472 having a distal end on which is formedchamfer 5474.

FIGS. 92 and 93 depict a slidable control element 5200 configured to beslidably received within vertical cylindrical recess 5534 of handle 5502of driver 5500, and retained therein by retainer 5530. Control element5200 has an upper portion 5210 sized to be slidably received withinopening 5532 of retainer 5530, a mid portion 5212 and a lower portion5220. Mid portion 5212 has formed therein symmetrically opposed first(distal) flat 5216 and second (proximal) flat 5214 with cylindrical hole5218 extending therebetween.

The elements of this alternate embodiment implant placement system 5000of the present invention comprising outer driver assembly 5500, innertensioning assembly 5400, and control element 5200 are depicted in FIG.94. Slidable control element 5200 with spring 5230 is inserted intovertical cylindrical recess 5534 and retained therein by retainer 5530.Inner assembly 5400 is inserted into proximal cylindrical recess 5504and proximal element 5452 is affixed to the proximal end of handle 5502.

FIGS. 95 through 99 depict implant placement system 5000 assembled andready for use. Proximal element 5452 of inner assembly 5450 (see FIG.94) is affixed to the proximal end of outer driver assembly 5500 handle5502. Control element 5210 is depicted in a first position wherein upperportion 5210 of control element 5200 protrudes above the top surface ofretainer 5530 and is maintained in that position by spring 5230. In thisfirst position, distal travel of outer driver assembly 5500 relative toinner tensioning assembly 5400 is constrained by contact between distalfacing surface 5466 of proximal portion 5476 of element 5456 andproximal surface 5214 of control element 5210, and initial compressionbeing imparted to spring 5454 thereby. Distal element 5412 of innertensioning assembly 5400 protrudes beyond implant 5600 a sufficientdistance to reach to bottom of a prepared socket while implant 5600remains proximal to the socket. As depicted in FIGS. 98A through 98C,when a proximal force is applied to distal element 5412 of innerassembly 5400 as when tensioning sutures for implant placement, proximalmotion of inner tensioning assembly 5400 relative to outer driverassembly 5500 is prevented by contact between proximal surface 5468 ofdistal portion 5472 of element 5456 affixed to tubular middle portion5410, and distal surface 5216 of control element 5210.

Applying a downward force to slide control 5200 sufficient to compressspring 5230 brings opening 5218 in slide control mid portion 5212 intocoaxial alignment with tubular mid portion 5410 and element 5456 mountedthereto such that distal portion 5472 of element 5456 may passtherethrough allowing outer driver assembly 5500 to advance distallyrelative to inner tensioning assembly 5400 to its distal limit asdepicted in FIGS. 100 through 104. Spring 5454 is compressed as depictedin FIG. 103. When slide 5200 is positioned as shown, outer driverassembly 5500 may be advanced distally with resistance to this axialmovement provided by force supplied by spring 5454. Outer driverassembly 5500 may also be simultaneously freely rotated relative toinner tensioning assembly 5400. Referring to FIGS. 98B and 98C, distalelement 5458, washer 5462 and proximal portion 5476 of element 5456together form a bearing, distal element 5456 and washer 5462 beingformed of a metallic material and optionally having a suitable lubricantapplied to their mating surfaces as well as on tubular mid portion 5410of inner tensioning assembly 5400.

Implant placement system 5000 places implant 5600 in the same manner assystem 1000 in that sutures passing through the graft are tensionedusing a non-rotating distal tensioning element that protrudes distallybeyond the implant a sufficient distance to allow the distal end of thedistal tensioning element to reach the bottom of a prepared socket withthe implant remaining proximal to the socket. Unlike system 1000, inwhich rotation of inner tensioning assembly 1400 is prevented by thesurgeon's control of hub 1402, prevention of rotation of innertensioning assembly 5400 is prevented by cooperative interaction betweenthe distal end 5413 of distal element 5412 of inner tensioning member5400 and the cortical bone at the bottom of the socket. The consistencyof the cortical bone at the bottom of a socket is such that it may bedeformed by distal end 5413 of distal element 5412 and by suturespassing into the cannulation of distal element 5412 due to axial forceapplied by the surgeon. This deformation increases the frictionalresistance to rotation of distal element 5412 and inner tensioningassembly 5400 of which it is a part. This resistance to rotation may befurther enhanced through the forming of suitable contours on distal end5413 of distal element 5412 so as to create features that may penetratethe cortical bone or create localized depressions therein. Thesecontours may include, for instance, protuberances, grooves, orcurvilinear shapes. Like implant system 1000, system 5000 has cleats5408 formed in inner tensioning assembly hub 5402 for maintaining thetension on sutures during placement of the implant. In otherembodiments, cleats 5408 are not formed in hub 5402 and the suturetension is maintained through friction between the cortical bone at thebottom of the socket and distal end 5413 of distal tensioning element5412 between which it is trapped.

When placing anchor 5600, the surgeon does not control inner tensioningassembly 5400 through hub 5402, but rather controls placement processexclusively through handle portion 5502 of outer driver assembly 5500and slide control 5320.

When using implant placement system 5000, suture is loaded intotensioning inner assembly 5400 as depicted in FIGS. 20 and 21 forimplant system 1000. Thereafter, anchor 5600 is placed as depicted inFIGS. 22, 25, 28, 31 and 32. In figures referenced in the followingdescription, depicted elements of implant system 1000 designated as“1XXX” may be replaced by their corresponding elements of implant system5000 designated as “5XXX”. FIG. 22 schematically depicts a socket 32formed by drilling or punching in bone 30, and a graft 20 to be affixedto bone 30. Sutures 1800 are passed through graft 20 in a usual manner;and the sutures loaded into system 5000 as previously described anddepicted in FIGS. 20 and 21, such that the suture proximal ends areaccessible to the surgeon. Subsequently, distal tubular portion 5412 oftensioning inner assembly 5400 is inserted into socket 32 as depicted inFIGS. 23 through 25, the distal end of tubular portion 5412 contactingthe bottom surface of socket 32. Thereafter, referring to FIGS. 26through 28, the surgeon grasps the proximal ends of sutures 1800 andwithdraws them proximally so as to advance graft 20 towards socket 32.When graft 20 is in the desired position, the proximal ends of sutures1800 are secured in cleats 5408 (FIG. 95) to maintain the graftposition. So long as the proximal ends of sutures 1800 remain securelycleated and the distal end of tubular element 5412 is maintained incontact with the bottom of socket 32, the position of graft 20 will notchange. The surgeon may adjust sutures 1800 as required to achieveoptimal placement of graft 20. When this optimal placement of graft 20has been achieved, while applying distal force to handle 5502 of implantsystem 5000 so as to maintain contact between the distal end off distaltubular element 5412 and the bottom of socket 32, the surgeon movesslide control 5300 to its second position (see FIG. 103) therebyallowing outer driver assembly 5500 with implant 5600 mounted thereto tobe moved distally so as to bring implant 5600 to socket 32, and to berotated so as to then thread implant 5600 into socket 32 so as to trapsutures 1800 between anchor 5600 and the wall of socket 32 in bone 30 asdepicted in FIG. 31. When anchor 5600 is fully inserted in socket 32,the proximal ends of sutures 1800 are then released from cleats 5408 andsystem 5000 is withdrawn from the joint, leaving the repair site asdepicted in FIG. 32. Subsequently sutures 1800 are trimmed adjacent toanchor 5600 and the anchor placement is complete. Upon withdrawal ofimplant placement system 5000 from the site, outer driver assembly 5500is returned to its proximal position (FIGS. 95 through 99) by forcesupplied by spring 5454, chamfered end 5474 of distal portion 5472 ofelement 5456 and opening 5218 cooperatively acting to return controlslide 5200 to its first position.

The initial compression applied to spring 5454 when assembled as shownin FIGS. 95 through 99, with outer driver assembly 5500 in itsproximal-most position, is sufficient to ensure that, after tensioningsutures 1800 in socket 32 prior to placing implant 5600, when slidecontrol 5320 is moved to its second position to allow outer driverassembly 5500 to move distally to bring the implant to the socket and toscrew the implant into the socket, distal end 5413 of distal tensioningelement 5412 remains firmly in contact with the cortical bone at thebottom of socket 32 so as to prevent rotation of inner tensioningassembly 5400.

In the method of implant placement previously described using placementsystem 5000, the tension in sutures 1800 and graft position aremaintained by removably storing the suture proximal ends in cleats 5408of inner tensioning assembly 5400. In an alternate method for placinganchor 5000, the tension in sutures 1800 and graft position aremaintained by the surgeon applying tension to the proximal ends ofsutures 1800, or by friction force applied to the portions of sutures1800 trapped between distal end 5413 of distal tensioning element 5412and the cortical bone at the bottom of socket 32, or by a combination ofthese two methods.

In an alternate embodiment, a loop of an elongate element such as, forinstance, nitinol wire may be formed distal to the distal end 5413 ofdistal tensioning element 5412 (see FIG. 99) with the proximal ends ofthe elongate element removably secured in cleats 5408 of hub 5402.Sutures may be loaded into the nitinol loop, tensioned, and secured byan anchor, whereupon the elongate element is removed. This method ofimplant placement is described in detail in the above-referencedco-pending and contemporaneously filed application entitled “CeramicImplant Placement Systems And Superelastic Suture Retention Loops ForUse Therewith” Ser. No. 15/256,815, the contents of which have beenpreviously incorporated by reference in their entirety.

FIG. 105 shows an exploded assembly of the elements of an alternateembodiment implant placement system of the present invention. Implantplacement system 6000 is identical in all aspects of form and functionto implant placement system 5000 except as specifically describedhereafter. For example, cannulated distal tensioning element 5412 ofsystem 5000 is replaced by distal tensioning element 6412 which is aliketo distal element 2412 (FIGS. 36 through 38) of implant placement system2000. Spring 5230 (FIG. 94) is eliminated such that slide control 6200may be positioned and remain in a first position in which axial motionof outer driver assembly 6500 is prevented (FIGS. 106 through 110), ormay be placed and remain in a second position in which the outer driverassembly 6500 may be advanced distally against force supplied by spring6454 (FIGS. 111 through 115). Hub 5402 of inner tensioning assembly 5400is eliminated, the rotation of inner assembly 6400 being controlled notby the surgeon's hand on a proximal hub, but rather through interactionbetween the distal end of distal tensioning element 6412 and thecortical bone at the bottom of the prepared socket. Maintaining theposition of the distal end of distal tensioning element 6412 at thebottom of the prepared socket is not accomplished through distal forceapplied to a hub like hub 2402 of the inner tensioning assembly 2400 aswhen using implant placement system 2000, but rather through distalforce applied to handle 6502 of outer driver assembly 6500 and anelastic element acting between inner tensioning assembly 6400 and outerdriver assembly 6500.

FIGS. 106 through 110 depict slide control 6200 in a first position withits topmost surface 6201 protruding above the top surface of retainer6530. In this configuration, distal axial movement of outer tensioningassembly 6500 is prevented by interaction between slide control 6200 andelement 6456 of inner tensioning assembly 6400 in the manner previouslyherein described with reference to implant placement system 5000. Aswith implant placement system 2000 (FIGS. 33 to 42), distal tensioningelement 6412 has formed thereon distally extending portions 6444separated by a gap 6446, distally extending portions 6444 havingsharpened distal ends 6448, the distal end of distal tensioning element6412 having the form of a fork. Sharpened distally extending portions6444 are configured so as to be able to pierce tissue or cortical bone,and gap 6446 is configured so that sutures placed therein may be made toslide smoothly for the purpose of tensioning a graft.

With slide control in its second position as depicted in FIGS. 111through 115, outer driver assembly 6500 of implant placement system 6000may be moved distally so as to bring implant 6600 mounted thereto to aprepared socket after the position of a graft is established, andsubsequently threaded into the socket. Top surface 6201 of slide control6200 is coplanar with the upper surface of retainer 6530 while bottomsurface 6203 of slide control 6500 protrudes beyond the adjacent surfaceportion of handle 6502 of outer driver assembly 6500.

To summarize, with slide control 6200 in its first position, axialmovement of driver assembly 6500 is prevented. With slide control 6200in its second position driver assembly 6500 rotates freely and may bemoved distally relative to inner tensioning assembly 6400, the axialmotion being resisted by spring 6454. Slide control 6200 is not returnedto its first position by a spring, but rather will remain in its secondposition until returned to its first position by the surgeon.

The method for placing an implant in accordance with the principles ofthe present invention is the same as the method when using implantplacement system 2000 and depicted in FIGS. 44 and 46 through 48 exceptas subsequently herein described. To that end, in figures referenced inthe following description, depicted elements of implant system 2000designated as “2XXX” may be replaced by their corresponding elements ofimplant system 6000 designated as “6XXX”. Slide control 6200 of implantplacement system 6000 is initially in its first position and thecondition of system 6000 is as depicted in FIGS. 106 through 110.Sutures 2802 are captured in gap 6446 between distally extendingportions 6444 at the distal end of distal tensioning element 6412 (seeFIG. 106B) and inserted with distal tensioning element 6412 into socket2032 as depicted in FIG. 44. Thereafter, as shown in FIG. 46, tension isapplied to sutures 2802 to bring graft 2000 to the present position. Thesurgeon maintains this tension so as to maintain the graft position. Thesurgeon then moves slide control 6200 to its second position andadvances outer driver assembly 6500 with implant 6600 mounted theretodistally to bring implant 6600 to socket 2032, and then threads implant6600 into socket 2032 as shown in FIG. 47. Distal force applied toimplant placement system 6000 via handle 6502 of outer driver assembly6500 causes sufficient interference between distal end features ofdistal tensioning element 6412 to prevent rotation of inner tensioningassembly 6400 during subsequent threading of anchor 6600 into socket2032. Compression of spring 6454 of inner tensioning assembly 6400applies sufficient distal force to ensure that contact is maintainedbetween the distal end of distal tensioning element 6412 and thecortical bone at the bottom of socket 2032. With implant 6600 threadedinto position as depicted in FIG. 47, the condition of implant system6000 is as depicted in FIGS. 111 through 115. FIG. 48 depicts the siteat the completion of implant placement.

With slide control 6200 in its first position, axial movement of driverassembly 6500 of implant placement system 6000 is prevented. With slidecontrol 6200 in its second position driver assembly 6500 rotates freelyand may be moved distally relative to inner tensioning assembly 6400,the axial motion being resisted by spring 6454. Slide control 6200 isnot returned to its first position by a spring, but rather may remain inits second position thereby giving the surgeon the option of insertingdistal tensioning element 6412 into a prepared socket and positioningthe graft through the adjustment of suture tension while relying solelyon the force supplied by spring 6454. The resisting force supplied toouter driver assembly 6500 by spring 6454 is sufficient to allowtensioning of sutures as previously herein described.

Implant placement system 6000 is depicted with inner assembly 6400having distal tensioning element 6412 with its distally extendingportion 6444. Inner assembly 6400 may be replaced by inner assembly 5400with its cannulated distal tensioning element 5412 and hub 5402 withoutdeparting from the principles of the present invention.

An alternate embodiment of the present invention incorporating asimplified construction is depicted in FIGS. 116 through 126. Implantplacement system 7000 is identical in form and function to implantplacement system 6000 except as specifically described hereafter. Forexample, control slide 6200 of implant placement system 6000 iseliminated so that outer driver assembly 7500 of placement system 7000may be advanced distally in the same manner as outer driver assembly6500 of implant placement system 6000 when control slide 6200 is in itssecond position. Implant 7600 is a push-in (interference plug) typeanchor which does not have a helical thread formed on its outer surface,but rather a plurality of tapered portions (best seen in FIG. 121).Implant 7600 has a planar proximal-most surface. Distal element 7512 ofouter driver assembly 6500 has a planer distal-most surface configuredfor transmitting axial force to implant 7600 during the placement ofimplant 7600. Push-in type implants and their use with embodiments ofthe present invention are described in the above-referenced co-pendingand contemporaneously filed application entitled “Ceramic ImplantPlacement Systems And Superelastic Suture Retention Loops For UseTherewith” Ser No. 15/256,815, the contents of which have beenpreviously incorporated by reference in their entirety. As notedelsewhere herein, push-in implants of the present invention may beformed of high strength ceramic materials.

FIG. 116 is a perspective view of an exploded assembly of the elementsof implant placement system 7000. Outer driver assembly 7500 is of asimple form with no external control means. FIGS. 117 to 121 depictimplant placement system 7000 with outer driver assembly 7500 in itsfully proximal position, maintained therein by spring 7454 of innertensioning assembly 7400. As seen in FIG. 120, element 7456 does nothave features for cooperative engagement with a slide control, butrather has a planar distal surface 7457. Cylindrical recess 7504 ofouter driver portion handle 7502 has a distal-most surface 7505 which,together with distal surface 7457 of element 7456, establishes theproximal limit of travel of outer driver assembly 7500 relative to innertensioning assembly 7400. As with implant placement systems 5000 and6000, the force supplied by spring 7454 is sufficient to prevent distaltravel of outer driver assembly 7500 during tensioning of sutures forpositioning of a graft.

FIGS. 122 through 126 depict implant placement system 7000 with outerdriver assembly at the distal limit of its travel as when implant 7600is fully placed in a prepared socket. Upon removal of implant placementsystem 7000 from the site at the completion of placement of implant7600, outer driver assembly 7500 returns to its proximal-most positionas depicted in FIGS. 117 to 121.

Implant placement system 7000 is used in the same manner as system 6000previously herein described except as subsequently described. Forexample, the surgeon is not required to move slide control 6200 to itssecond position prior to advancing implant 7600 to the prepared socket.The surgeon is thus able to place implant 7600 with a first handsupplying tension to the sutures for graft positioning, and a secondhand, via handle 7502 of outer tensioning assembly 7500, insertingdistal tensioning element 7412 into a prepared socket, and thereaftermaintaining the position of element 7412 during positioning of a graft.When the graft is properly positioned, implant 7600 is incrementallydriven axially into the prepared socket by repeatedly impacting proximalend cap 7452 with a mallet. When implant 7600 is fully inserted,placement system 7000 is removed from the site and the repair iscompleted.

While methods of use of implant systems 5000, 6000 and 7000 have beendescribed with reference to placing an implant so as to maintain a graftposition by the trapping of sutures between the implant and at least onewall of the socket, these systems may also be used for bio-tenodesisprocedures as depicted in FIGS. 49 through 52, FIGS. 53 through 57, andFIGS. 58 through 63 as well as other embodiments contemplated by thepresent invention.

INDUSTRIAL APPLICABILITY

As noted previously, there is a need in the art for simplified placementsystems and methods for tissue graft anchors by which the surgeon mayintroduce one or more sutures into a prepared socket in the boneytissue, apply tension to the sutures to advance a soft tissue graft to adesired location, and then advance an anchor into the bone whilemaintaining suture tension. The present invention addresses this need byproviding a system and method for the placement of an implant,especially a suture anchor, threaded, knotless or otherwise, that allowsthe surgeon to establish the graft position and, while maintaining thatposition, secure the anchor without changing the suture tension orcausing a shift in the graft position and furthermore, when the anchoris threaded, without spinning of the suture. The present invention alsoprovides off-axis socket drills and implant driving devices that enableimplantation in remote and difficult to access boney surfaces usingminimally invasive procedures. The present invention further providesembodiments in which the relative axial movement between the innertensioning device and outer driver device is physically constrained, forexample by means of springs and the like, so as to allow for one-handedoperation. Although described in detail with respect to ligamentrepairs, such as repair of a torn rotator cuff, it will be readilyapparent to the skilled artisan that the utility of the presentinvention extends to other tissues and injuries.

The disclosure of each publication, patent or patent applicationmentioned in this specification is specifically incorporated byreference herein in its entirety. However, nothing herein is to beconstrued as an admission that the invention is not entitled to antedatesuch disclosure by virtue of prior invention.

The invention has been illustrated by reference to specific examples andpreferred embodiments. However, it should be understood that theinvention is intended not to be limited by the foregoing description,but to be defined by the appended claims and their equivalents.

What is claimed:
 1. An implant placement system for affixing a softtissue graft to a prepared socket in a boney surface via a cannulatedanchoring implant, said system comprising: a. a cannulated driver devicecomprising a proximal handle portion having an open proximal end, anelongate tubular distal portion that defines the longitudinal axis ofthe system and includes an open distal end configured to receive saidimplant, and at least one driver lumen extending from said open proximalend to said open distal end; b. an elongate insertion device comprisinga proximal hub portion and a rigid distal portion configured to receivethe first ends of one or more elongate sutures; and c. an axial controlassembly having a first constrained configuration and a second freeconfiguration; wherein: i. said insertion device is slidably receivedwithin said at least one lumen of said driver device and the proximalend of said driver device handle portion is engaged to the distal end ofsaid insertion device hub portion; ii. when said axial control assemblyis in said first constrained configuration, the distal end of saidinsertion device extends distally past the distal end of said implantwhen coupled to said driver device so as to enable said insertion devicedistal end to receive said suture first ends and relative axial movementbetween said driver device and said insertion device is precluded; andiii. when said axial control assembly is in said second freeconfiguration, the driver device and implant move axially in a distaldirection along the length of said rigid distal portion of saidinsertion device to thereby drive said implant into said socket whilethe insertion device is maintained in a fixed position.
 2. The implantplacement system of claim 1, wherein said axial control assemblyincludes a longitudinal spring contained within said proximal hubportion.
 3. The implant placement system of claim 2, wherein saidlongitudinal spring is held in a compressed configuration by one or moreslidable control elements.
 4. The implant placement system of claim 3,wherein said slidable control element includes extends through a lateralwall of said proximal hub portion and is transversely oriented to thelongitudinal axis.
 5. The implant placement system of claim 1, whereinsaid implant comprises an interference plug-type anchor.
 6. The implantplacement system of claim 1, wherein said implant comprises a threadedanchor.
 7. The implant placement system of claim 1, wherein said implantcomprises a cannulated knotless suture anchor fabricated from a highstrength ceramic material selected from the group consisting of aluminaand zirconia.
 8. The implant placement system of claim 1, wherein thedistal end of said driver device and a proximal end of said implant areprovided with mating features that enable secure attachment of saidimplant to said driver device.
 9. The implant placement system of claim8, wherein both the implant and at least the mating features of saidcannulated driver device are shaped by Ceramic Injection Molding (CIM).10. The implant placement system of claim 1, wherein the distal end ofsaid driver device includes torque transmitting features that, togetherwith complementary torque receiving features formed in a proximalportion of the anchor, allow the transmission of torque to said anchornecessary to drive said anchor into said prepared socket.
 11. Theimplant placement system of claim 1, wherein said rigid distal portionof said insertion device has at its distal end a sharpened fork portioncharacterized by two or more axially extending tines spaced apart todefine one or more channels therebetween in which said one or more firstends of said one or more elongate sutures may be slidably received. 12.The implant placement system of claim 1, wherein said elongate insertiondevice further comprises an open proximal end, an open distal end, andat least one insertion lumen extending from open proximal end to saidopen distal end.
 13. The implant placement system of claim 12, whereinsaid system further comprises an elongate element formed from a suitablyelastic metallic or polymeric material and having a first configurationcharacterized by first and second free proximal ends and distal end inthe form of a suture capturing loop configured to receive the first endsof one or more elongate sutures; wherein: i. said insertion device isslidably received within said at least one driver lumen such that rigiddistal portion extends out of the open distal end of said driver deviceand distally past the distal end of said suture anchor when coupled tosaid driver device; and ii. said elongate element in said firstconfiguration is slidably received within said at least one insertionlumen such that the suture capturing loop extends out of and distallypast the open distal end of said insertion device so as to enable saidsuture capturing loop to receive said suture first ends.
 14. A methodfor affixing a soft tissue graft to a target boney surface, the methodcomprising the steps of: a. providing the implant placement system ofclaim 1 with the proximal end of said driver device handle portionengaged to the distal end of said insertion device hub portion and theaxial control assembly in said first constrained configuration, wherebyrelative axial movement between said driver device and said insertiondevice is precluded; b. positioning an anchoring implant to the distalend of said driver device; c. providing one or more elongate sutures,each of which has a first free end and a second end attached to saidsoft tissue graft; d. receiving said first free ends in the distal endof said insertion device; e. inserting the distal end of the insertiondevice into a suitably configured socket disposed in said target boneysurface; f. applying tension to the suture to draw the soft tissue graftto a desired position; g. shifting said axial control assembly to saidsecond free configuration; and h. distally advancing said driver deviceso as to drive the implant in the socket, whereby said implant serves toanchor said soft tissue graft to said target boney surface.
 15. Themethod of claim 14, further comprising step (i) of withdrawing theimplant placement system after step (h).
 16. The method of claim 14,further comprising step (j) of trimming the free end of said sutureafter step (i).
 17. The method of claim 14, further comprising repeatingsteps (b) through (h) as required.
 18. The method of claim 14, whereinsaid anchoring implant comprises an interference plug-type anchor,further wherein the distal end of said driver device and a proximal endof said interference plug-type anchor are provided with mating featuresthat enable secure attachment of said anchor to said driver device. 19.The method of claim 14, wherein said anchoring implant comprises athreaded anchor, further wherein the distal end of said driver deviceincludes torque transmitting features that, together with complementarytorque receiving features formed in a proximal portion of the anchor,allow the transmission of torque to said anchor.